HORMONES Flashcards
Why do we get AM cortisol levels?
because peak plasma concentration between 4 am - 8 am
What kind of feedback does HPA axis have
negative feedback
What releases CRH +?
Hypothalamus
What releases ACTH+?
What releases cortisol?
cortisol is bound to?
Pituitary releases ACTH
Adrenal releases cortisol
Cortisol is highly protein bound
Why would your HPA axis wont work?
What causes adrenal insufficiency?
acute setting: hemodynamic instability
What are the clinical manifestations of adrenal insufficiency?
What are the laboratory findings?
Common clinical manifestations of CIRCI
Common clinical manifestations of CIRCI
• Hypotension
- Unresponsiveness to catecholamine infusion
- Ventilator dependence
How to Diagnose CIRCI using ACTH stim test
ACTH stimulation test
- Dosing of IV ACTH is controversial – 250 mcg vs 1 mcg
- Adrenal insufficiency if delta ≤9 mcg/dL after 250 mcg dose
A steroid that does not impact ACTH results
Dexamethasone
Managemet of CIRCI
take home points
What has the highest mineralcorticoid potency is
Fludcortisone
What should be on your differential for refractory hypotension?
Adrenal insufficiency esp. if you gave etomidate
Adrenal insufficiency and etomidate
Reduction of corticol secretion in etomidate
doesn’t translate to long term outcomes
Management of CIRCI w/o septic shock
Taper is not needed for steroid duration <7 days
If someone is exposed to <5 mg /day
—> can be
considered not to have a suppression of HPA axis
Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily
MINOR SURGERY
Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily
MODERATE SURGERY
Management for periopertive steroids in patients receiving chronic prednisone 5 mg daily
MAJOR SURGERY
and
Critically ill
What is the maximum hydroctortisone treatment can you have if you are in septic shock and steroid naive
200 mg/ daily
- If you have been chronically exposed >200 probably 300
Surviving sepsis campaign
How much steroid is recommended
What about random cortisol level
Optimal duration of therapy?
What are the adverse effects of glucocorticoids?
- Suppression of the HPA axis
- Hypergylycemia
- Skeletal muscle myopathy
- Leukocytosis / infection
- Infection
- Decrease wound healing
- Psychosis
How is insulin delivery affected?
What is type 1 diabetes?
What is type 2?
Side effects of insulin
- Insulin resistance
- Defined as the daily need for > 100 units of exogenous insulin
- Acute insulin resistance is associated with trauma from infection or surgery
What do you need to know for Sulfonylureas?
What is the SE of Metformin?
what does it cause?
* common diabetic preOp
*** metformin should be held.
LACTIC ACID CAN BE SEE
What are the commonly used Sulfonylureas
If the patient has AKI and they have taken Sulfonylureas– then they are likely to experience hypoglycemia POST-OP
T/F
Tighter glucose control in critically ill patients has been independently associated with increased ICU mortality
true
§ Some studies show no difference in mortality
What is the presentation of DKA?
who commonly has it?
Diabetic ketoacidosis (DKA)
- Combination of hyperglycemia (BG >250 mg/dL) + ketosis (positiveurine or serum ketones) + acidosis (pH <7.30 with serum bicarbonate <18 mmol/L and anion gap >10)
if you add depressed mental status then its SEVERE DKA
they have to gave 3
– COMMONLY PRESENT WITH TYPE 1
What is the presentation of HHS?
hyperglycemia is much higher.
often occurs with type 2 dm
Management of DKA and HHS
- Massive amount of fluid resuscitation
- Insulin IV
- Electrolyte replacement –> be careful with potassium
the patient may be hyperkalemic at first because they are volume down.
–> REPLACE K if hypokalemic before you start insulin
- Correction of acidemia–> BICARB should not be given.
